Uterine Wall Thickening

What is the Uterine Wall?

The uterine wall is the structure that lines the cavity of the uterus. The uterine wall (endometrium) thickens before each menstrual period under the influence of hormones, preparing a suitable thickness and nourishing blood vessel network for the implantation of an embryo if pregnancy occurs. If pregnancy does not occur, the thickened uterine wall is shed through menstruation due to the cessation of hormonal support. The uterine wall is a functional structure that is influenced by hormones and changes accordingly.

What is Uterine Wall Thickening?

Uterine wall thickening refers to a condition where the thickness of the uterine wall exceeds established measurements or becomes asymmetric for different age groups of women. There are specific measurements for endometrial thickness during menarche (first menstruation),adolescence, young adulthood, and menopause. If there is a deviation from these measurements, procedures such as reducing excessive thickness to normalize heavy menstrual bleeding and performing a biopsy may be necessary.

Although there are various causes of uterine wall thickening, it is crucial to take a tissue sample. Uterine wall thickening, even if not indicative of cancer, can be a warning sign of uterine cancer.

What Causes Uterine Wall Thickening?

The menstrual cycle in women occurs due to certain fluctuations in the hormones estrogen and progesterone. The role of estrogen in the uterine wall is to stimulate the thickening of the endometrium and prepare it for pregnancy. Uterine wall thickening occurs when estrogen levels are excessively high or when progesterone is insufficient to counterbalance estrogen. Hormonal imbalances can occur due to various reasons.

Uterine wall thickening can be caused by;

• Overweight women, as fat tissue produces estrogen.
• Women with diabetes.
• Women undergoing hormone replacement therapy after menopause.
• Women with insufficient progesterone secretion (those with a short luteal phase).
• Women with PCOS (Polycystic Ovary Syndrome).
• Ovarian cancer or other hormone-producing cancers.
• Women with a history of breast cancer who are undergoing tamoxifen treatment.
• Women who have never given birth.
• Women with irregular menstrual cycles.
• Women with endometrial polyps.
• Women with a family history of cancer.
• Women with liver disorders.

In these cases, a biopsy should be performed.

What are the Symptoms of Uterine Wall Thickening?

Uterine wall thickening most commonly manifests as excessive menstrual bleeding. This is especially concerning in postmenopausal women. Symptoms like a menstrual cycle shorter than 21 days (due to hormonal imbalance),painful and prolonged menstruation, and heavy bleeding may indicate uterine wall thickening. Since these symptoms can be early signs of uterine cancer, it is important to consult a doctor.

What Happens if the Uterine Wall is Thick?

If the uterine wall is thick, menstrual bleeding will increase, and menstrual cramps will become more pronounced. Conditions like endometrial polyps can increase uterine contractions, causing pain that may not be relieved by painkillers. Since uterine wall thickening can be a precursor to conditions such as endometrial cancer, it is crucial that an ultrasound examination is performed by an experienced and careful doctor.

What Does Uterine Wall Thickening Indicate?

Uterine wall thickening can be an indicator of several conditions, including;

• Uterine cancer (can be distinguished by ultrasound).
• Early-stage uterine cancer.
• Endometrial hyperplasia (a precursor to uterine cancer; biopsy is necessary for diagnosis).
• Endometrial polyps.
• Uterine septum.
• Hormonal imbalances.
• Liver disease.

Therefore, uterine wall thickening should be investigated thoroughly.

When is Uterine Wall Thickening Dangerous?

Uterine wall thickening becomes dangerous when it is not diagnosed and treated. It can lead to prolonged, painful, and excessive menstrual bleeding. In postmenopausal women, bleeding is particularly concerning as it increases the risk of cancer. Early-stage uterine cancer can also be signaled, and obtaining a tissue sample is crucial for improving the chances of survival. Endometrial hyperplasia, a precursor lesion to uterine cancer, is commonly seen in cases of uterine wall thickening, so early diagnosis and treatment are vital before cancer develops.

What is Endometrial Hyperplasia?

Endometrial hyperplasia is a precursor lesion to uterine cancer (endometrial cancer). It is classified into two types: atypical (high risk of cancer) and non-atypical (low risk of cancer). Both types can be managed with progesterone hormone therapy and estrogen reduction to prevent cancer from developing.

If the patient has never had children, preserving the uterus is crucial to facilitate future pregnancies. Approximately 20% to 5% of patients with endometrial hyperplasia will develop uterine cancer, which is why uterine wall thickening, as a sign of endometrial hyperplasia, requires biopsy and treatment to prevent cancer from occurring.

How to Treat Endometrial Thickening?

After the diagnosis of endometrial thickening, three methods can be applied:

1. Endometrial Curettage: This is the process of cleaning the thickened endometrium with curettage instruments under local or mild general anesthesia. While performing endometrial curettage, samples should also be taken from the endocervical (cervical) area. The structure of the cells in the uterus and cervix is different, so it is crucial to make a clear pathological distinction. Since the primary disease of endometrial thickening could be in the cervix, it is necessary to perform the curettage procedure simultaneously from both the endometrial (uterine) and endocervical (cervical) regions, and send the samples to pathology in different containers.
2. Hysteroscopy: This procedure is performed by inserting a flexible camera into the uterus. The areas causing the thickening of the uterine wall are clearly visualized, and samples are taken. This method is particularly preferred in cases of uterine polyps or irregularities. However, it requires hospital conditions and general anesthesia, which are disadvantages compared to curettage.
3. Pipelle Sampling: This method is advantageous because it can be performed in office conditions, especially in postmenopausal women. However, pipelle sampling may not always provide sufficient tissue samples. Since endometrial thickening in postmenopausal women significantly increases the risk of cancer, this method is not preferred. Insufficient tissue samples may lead to missed diagnoses.

Is Endometrial Thickening Cancer?

Endometrial thickening is related to cancer in 5% to 20% of cases. Women who are overweight, have never given birth, or have hormonal imbalances with irregular menstruation are at a significantly higher risk of developing cancer. Therefore, it is very important for women with irregular menstruation to consult a gynecologist.

Is There a Medical Treatment for Endometrial Thickening?

In patients diagnosed with endometrial thickening, the first step is to surgically clean the thickened uterine lining and send it for pathological examination.

If the patient has cancer and has given birth, a hysterectomy (removal of the uterus) should be performed. If the patient has cancer but has not given birth or is in the early stages of cancer, treatment is given to reduce estrogen and provide daily progesterone support. However, curettage should be repeated every six months to monitor the uterine lining and prevent cancer transformation.

In cases of low-grade endometrial hyperplasia, progesterone support is provided. However, if the hyperplasia is atypical, hysterectomy should be performed in women who have given birth to prevent the progression to cancer.

If the pathology of the endometrial thickening comes back clean, progesterone therapy is used to reduce estrogen effects and eliminate cancer risk in the following years. Additionally, progesterone treatment will regulate menstrual bleeding and eliminate excessive and painful periods.

Progesterone Treatment: This can be administered orally, vaginally, or via an intrauterine device (IUD) containing progesterone. The treatment effectiveness is the same for each method. The treatment choice is determined based on the patient's lifestyle and preference.

Natural/Functional Adjunct Treatments for Endometrial Thickening:

• Weight loss
• Reducing excess estrogen hormonally
• Taking supplements that promote the elimination of harmful estrogen metabolites from the body
• Improving liver function
• Mediterranean-style healthy eating
• Engaging in moderate exercise at least twice a week
• If postmenopausal hormone therapy is being used, switching to benign estrogen creams and, if possible, using herbal support to alleviate hot flashes with functional medicine methods.

Does Endometrial Thickening Affect Sexuality?

Endometrial thickening can negatively impact sexuality due to irregular menstruation, painful periods, and excessive bleeding. The excess tissue in the uterus can cause cramping, which may lead to mild discomfort during intercourse. All these symptoms can be alleviated with treatment.